Reminiscing can spur positive thinking
Few people know more about the anger, fear, and guilt terminally ill patients harbor as they come to grips with their approaching death than the hospice worker charged with helping patients and their families handle those negative emotions and achieve a good death.
Two Minnesota psychologists say exercises in story-telling can help dying patients move past debilitating emotions by allowing the patient to view his or her life more positively and bringing family members closer.
"The idea is to empower the person to help them affirm their life experience," says Howard Thorsheim, PhD, professor of psychology at St. Olaf College in Northfield, MN. "We have found that story-telling is the glue that binds us together."
Thorsheim is the co-author of I Remember When, along with Bruce Roberts, PhD, professor of psychology at St. Olaf College. The book is based on a 1996 study of more than 10,000 people.
Thorsheim’s and Roberts’ research on story-telling measured its value to the elderly, but Thorsheim says there are direct applications to the terminally ill and their caregivers.
According to Thorsheim and Roberts, reminiscing and telling stories helps people find common ground with others and engage in a social process that brings about mutual support that is empowering. Empowerment, under the two researchers’ definition, is a sense of well-being and a feeling that one’s life has meaning. In the hospice setting, story-telling can help the dying patient feel empowered by giving the patient a chance to focus on positive life experiences. Encouraging patients to share their stories can also strengthen familial bonds.
Creating opportunities for support
The value of story-telling, according to the authors, is in creating opportunities for social support from family and friends. Their research showed that as people get older, they have fewer opportunities to feel supported by family and friends. The same can be said for the dying, who often feel isolated and angry.
As a result, self-esteem is affected because of the lack of support. Self-esteem is even more dramatically affected in dying elderly patients. The authors noted that men of retirement age experience drops in self-esteem because they feel their life has lost its meaning. If a terminal illness is thrown into the mix, the patient’s ability to achieve a meaningful death can be hindered by the perception that his or her life has lost meaning and the perception of diminished support from friends and family.
The goal of hospice workers is to help patients resolve these negative emotions in a way that allows them to begin addressing their social and spiritual needs.
The five benefits of story-telling
According to Thorsheim, story-telling provides five benefits that promote life affirmation and help patients along the road:
- A sense of belonging. Telling stories helps people feel closer to their families, community, and physical surroundings.
- Makes one’s name known to others and others’ names known to the person. Story-telling promotes an emotional connection between people who otherwise would be strangers. It can help hospice workers break through walls and nurture a familiarity that precedes trust.
- A sense of caring. Sharing stories promotes a closeness among individuals through sharing details of one’s life and perceiving that others are listening and interested.
- Sets up care. Story-listening is a skill that sets the stage for giving care, while story-telling fosters trust that allows one to be cared for.
- Provides an opportunity to ask for help. A story can often provide clues to the listener as to which emotions a person is struggling with and how to help the person resolve those emotions.
But getting hospice patients to reveal intimate details of their lives is not a simple task. It requires the patient to trust the caregiver, not only to keep confidence, but to receive favorably their efforts to share. If the patient believes the story is of little significance to the listener, the listener likely will cause the patient to retreat, making future story-telling more difficult.
Listening is a skill that could be improved in many people. Fortunately, most people possess the skills to become good listeners. According to Thorsheim’s and Roberts’ book, aspects of good listening include the following skills:
- Develop good eye contact. Look at the speaker when he or she is sharing a life experience.
- Ask open questions. Ask for more details through simple open-ended questions. For example, ask, "Can you tell me more about that?" Asking for more details adds weight to the importance of the speaker’s story.
- Paraphrase what the speaker is saying. In your own words, offer a quick summary of what the speaker just told you. This shows the speaker you are interested in their story and promotes sharing of additional details.
- Reflect the speaker’s feelings. Saying something like "that must have made you happy," shows the speaker you understand the emotions they experienced.
- Know when to keep quiet. Allow the speaker to tell his or her story without interruption. For example, don’t start in with a story of your own until the speaker has finished.
- Respect the speaker’s experience. Don’t belittle what the speaker did just because you would have done it differently.
- Concentrate on what the speaker is saying. If you are going to find common ground with the speaker, you will need to think about what is being said. If necessary, ask questions that would make the story more interesting.
Prompting people to share their life experience can be as easy as asking them to tell you a story from their life, but often it takes a little more planning and prompting, says Thorsheim.
How to establish trust
One strategy involves asking the patient about something specific that is likely to have significance in his or her life. For example, if the patient is a war veteran, ask where he or she served. If there aren’t any obvious clues as to significant life experiences, Thorsheim says caregivers can use the patient’s surroundings and mementos for topics of discussion.
Still, patients may be reluctant to open up. Gaining trust is a hurdle hospice workers must overcome. People often withhold trust because they are unsure what will be done with the information shared. They may be afraid that the listener won’t find the story interesting, or that the listener will take a negative view of the story.
It’s not uncommon for hospice workers to begin caring for a new patient who is reluctant to offer more than short answers to workers’ questions. For example, a simple "how are you?" garners the response "okay" with little elaboration on how the patient is actually feeling.
Thorsheim says it may be helpful if both speaker and listener establish exactly what will be discussed so the speaker will feel comfortable and will not worry that he or she will share more than the listener is willing to hear. For the hospice worker trying to prompt the patient into story-telling, Thorsheim says it’s important not to probe too deeply too soon. He recommends focusing on a picture or object on display in the patient’s home, because it provides a safe boundary between what is open for discussion and what is too personal.
Practice listening skills
Hospice workers can engage in listening exercises to improve their listening skills and become more effective at getting patients to open up.
As part of an interdisciplinary team meeting or an inservice program, Thorsheim says each attending member should bring an object that has a story behind it. Attendees should break up into pairs and take turns telling their story. The exercise begins with the listener asking the speaker about the object. The speaker then responds with a short answer that does not offer much detail, simulating reluctance to open up.
"The person has two minutes to tell their story, withholding information to prompt the listener to ask open questions," says Thorsheim. "It’s a powerful exercise. It promotes a level of conversation that requires trust."
The listener not only learns to ask more questions, paraphrasing when appropriate, but also to concentrate on what the speaker is saying to keep the conversation going. The exercise should last about 20 minutes, with the two participants switching roles afterwards.
Thorsheim adds that health care workers who provide care in the home have an ideal opportunity to encourage those isolated by their illness to reminisce and look at their life as a whole, rather than in the narrow context of their illness.
"It feels good when people listen to us, express their appreciation of us, are open with us, and include us," Thorsheim and Roberts wrote in their book. "When this happens we have a sense of well-being and a feeling that our life has meaning. When we are asked to tell stories of our life experiences and someone listens to us, we feel empowered."
[Editor’s note: I Remember When (Thorsheim H, Roberts B. Forest Knolls, CA: Elder Books; 2000) is available by mail through Elder Books, P.O Box 490, Forest Knolls, CA 94933. The book costs $18.90.]
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